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SANJOAQUIN Environmental Health Department <br /> -.. . _ - COU NTY -- -- - <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 626-627-8316 <br /> C Facility Name Kwik Sery Boyett Petroleum #98 Phone # 209- 549-5612 <br /> 1 Address2501 Jackson Ave Escalon , CA <br /> L <br /> I Cross Street David Drive <br /> T <br /> Y Owner/OperatorBoyett Petroleum - Monica Farhat Phone # 209- 549 -5612 <br /> C Contractor NameCGRS , Inc . Phone # 916- 991 - 1100 <br /> 0 <br /> T Contractor Address 5444 Dry Creek Road Sacramento , CA 95838 CA Lic # 803616 ClassA/HAZ <br /> A InsurerPinnacol Assurance Work Comp # 4029480 <br /> T ICC Technician 's Name Richard Thomas Expiration Date 9/21 /24 <br /> R ICC Installer' s Name RichardExpiration Date 9/21 /24 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc. ) Installed <br /> T Diesel spill bucket diesel <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A r, <br /> N Plan Reviewers Name Date ( _` toILI <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : " I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER 'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER 'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature / /L8/�YLCt Title Compliance Services Manager Date 8- 7- 2024 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Matt Thomas TITLE Compliance Services Manager PHONE # 626 -627- 8316 <br /> ADDRESS 5444 Dry Creek Road Sacramento , CA 95838 <br /> SIGNATURE / /7BhLCl DATE 8- 7- 2024 <br /> 2 of 6 <br />